Provider Demographics
NPI:1609047430
Name:HALEH NEKOORAD-LONG,M.D.,P.C.
Entity Type:Organization
Organization Name:HALEH NEKOORAD-LONG,M.D.,P.C.
Other - Org Name:COLORADO MOOD AND MEMORY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HALEH
Authorized Official - Middle Name:
Authorized Official - Last Name:NEKOORAD-LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-682-9197
Mailing Address - Street 1:1308 VIVIAN ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3217
Mailing Address - Country:US
Mailing Address - Phone:303-682-9197
Mailing Address - Fax:
Practice Address - Street 1:1308 VIVIAN ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3217
Practice Address - Country:US
Practice Address - Phone:303-682-9197
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41484174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1952492571OtherINDIVIDUAL NPI
COH46661Medicare UPIN